Battling Radical Mastectomy

Nonmedical publications about breast cancer have evolved in the past three decades from occasional uplifting memoirs by women who survived it to the current stream of books taking broader perspectives on this familiar and dreaded disease. The Breast Cancer Wars, Barron H. Lerner's examination of breast cancer detection and treatment in the 20th century, provides an excellent analysis of the conflict between maturing scientific approaches and traditional clinical practices.

The bulk of Lerner's book analyzes the persistence of the radical mastectomy, the treatment of choice in the United States from the early 1900s until the late 1970s. Developed by William S. Halsted, an eminent European-trained surgeon at Johns Hopkins School of Medicine, radical mastectomy removed not only the affected breast, but the underarm lymph nodes as well as both of the chest wall muscles on the affected side. This disfiguring and debilitating surgery was performed on virtually every woman who presented with the disease, regardless of the degree of the cancer's severity at the time of diagnosis. By the time Halsted died in 1922, surgeons he had trained in the nation's most respected medical school had fanned out across the country and were disseminating his ideas and techniques.

As early as the 1940s, evidence was beginning to accumulate that less invasive surgery yielded comparable survival rates, but followers of Halsted aggressively defended their practices. Not until 34 years after the first popular call for modifying the extensive surgery, by George (Barney) Crile, Jr., of the Cleveland Clinic in 1955, did surgeons at Columbia-Presbyterian Hospital in New York City, one of the last bastions of radical breast surgery, lay down their instruments and acknowledge that the Halsted era had come to an end. The theory that breast cancer is a local disease that can invariably be contained if treated early was supplanted by the assumption that it is a systemic disease whose course is determined by its biological activity.

Medical historians have noted reluctance to amend medical routine generally, but the struggle to overcome this unnecessarily harsh and antiquated treatment was unusual in that it was fought in the public eye. The ascendance of Halsted and his radical mastectomy paralleled the rise of modern medical education. Halsted was the leader of the first surgical training program in the United States, and his students became pioneers of that profession. The founding of the American Cancer Society, between the two world wars, promulgated military language with respect to cancer, reinforcing battlefield imagery and ideology: Good patients were brave soldiers, and those who operated on them took bold and heroic measures to vanquish the enemy disease. The Halsted mastectomy had its demise hastened by the modern women's health movement, and it was buried by the only randomized clinical trial to compare survival rates from different types of surgery.

Although most of the book follows the fascinating history of the Halsted radical surgery and the colorful people who were its adherents and detractors, Lerner also investigates analogous issues, particularly screening mammography and genetic testing. He understands the difficulties in applying knowledge derived from populations to individual cases and is respectful of the choices women make in situations that are not only urgent and complex, but murky as well. He is also cognizant of the role that industry plays in creating demand for new technologies and products as it asserts its growing influence over medical research.

A physician as well as a historian, Lerner cites a wide variety of sources?medical and scientific journals, news accounts, advocacy organization newsletters, government documents, personal papers and archives, and interviews with dozens of principals, including surgeons, oncologists, patients, journalists, ethicists and advocates. The 70 pages of endnotes are an extraordinary resource for those with an academic interest in the history of breast cancer and its treatment. His analyses reflect a broad understanding of historical and social movements that shaped the 20th century, including not only medical education and political history, but also economics, feminism and the growth of advocacy organizations for women with breast cancer.

Lerner's motivation for taking on this topic was in part the experience of watching his mother deal with breast cancer when he was an adolescent. Although sensitive to the ways in which physicians influence women's decisions about treatment, he clearly accepts the argument that these choices are in a woman's hands, regardless of how parochial or misinformed her doctor may be. This approach is quintessentially American, but it fails to acknowledge that informed choice is circumscribed by a paucity of clear information about treatment outcomes, even after years of vastly increased spending for breast cancer research.?Jane Zones, Social and Behavioral Sciences, School of Nursing, University of California, San Francisco